Noises From the Attic…

An assistant at Bewick Lodge Care Home in Lemington, Newcastle, has pleaded guilty to yanking the hair of an eighty-nine-year-old dementia victim and drenching her in water. He has been given a community order and told to pay fifty pounds in compensation to his victim. Perhaps this eighty-nine-year-old is made of strong stuff but I doubt that a few tenners will make up for such pain, fear and disorientation. It’s barely enough to make up for a stubbed toe.

The man had been dismissed from a previous care home job after directing abusive, threatening language towards residents, and is said to endure Asberger syndrome. It is a depressing indictment of our system that a man who not only lacks communication skills and empathy but had demonstrated that he is so deficient in these virtues that he could threaten elderly people was charged with caring for disabled octogenarians. What on earth did they expect when they employed the man?

I have been writing notes on this subject since the Winterbourne View scandal in 2011, which saw Panorama expose widespread abuse at a care home near Bristol. “Never again” was the cry that went up in the aftermath of the programme. It is worth reflecting on the issue at greater length both because it has happened again and because the inadequate official response will ensure that it continues to happen again. And again. Et cetera.

Britain’s social care system has been expanding and will continue to expand as more people live longer lives and require greater support. Governments have failed to explore and promote means of maintaining the health and independence of the ageing, which could both improve their lives and ameliorate the risk of soaring costs, yet it remains unavoidable that millions will need care.

The system is inconsistent, and provides very good and very bad services, but it would not be unjust to give the broad assessment that we do not seem concerned with giving the aged and the disabled the best quality of life that could be reasonably offered them. (Thousands of old people, for example, seem to be given antipsychotic drugs that do no good to them and endanger their health because they shut them up.) What should be unarguable – the baseline from which standards of care could be devised – is that no one, least of all people who age or disabilities have made frail and sensitive, should be subjected to violence and intimidation.

It sounds obvious yet to many people it might come as something of a revelation. According to the Care Quality Commission, tens of thousands of people are reported to have faced abuse and neglect each year. These can represent cases of petty spite, such as when a thug in Staffordshire took it upon himself to shout “boo” in an old woman’s face, or dramatic violence. One male nurse was filmed striking an eighty-year-old victim of Alzheimer’s disease.

This phenomenon is representative not just of rotten apples but a rotten orchard. Most care workers are, of course, decent and assiduous people who have taken on a job that, when performed correctly, is rather more difficult than most. Yet the low, indeed almost non-existent standards by which one can acquire and maintain such a job have attracted far too many of the angry, irritable and unintelligent men and women who are least capable of performing its duties.

Staff of the questionable character of the assistant at Bewick Lodge have also been allowed to lodge themselves within the system. According to the NHS Information Centre, five percent of suspects in reported cases of abuse have faced the sack while one percent have been referred to watchdogs to investigate whether they should be excluded from their profession. These are, of course, reported cases, and many of the suspects would have been innocent, yet stories such as that emerging from Lemington suggest that others have been guilty yet somehow clung to their careers. This is disgraceful. The abusive should enjoy no “…strikes and you are out” rule.

The government plans to introduce compulsory training for care home staff. On Question Time in 2011 a mild-mannered representative of Plaid Cymru observed that minimal training could have been a factor in the Winterbourne View scandal. He was mocked by a collection of knee-jerking ninnyhammers – which included Stephen Dorrell, the Conservative MP – for supposedly implying that abusers only have to be told not to bully people. His actual point, as the government seems to be acknowledging almost two years later, was that if greater demands are made of applicants the worst of them may not apply.

It would have been nice if the Conservatives had paused to reflect on this before all of the scandals of the last twenty-two months. (Perhaps they can grant that Plaid Cymru were well ahead of them.) Still, we can hope that it is true, and that more training will also lead nurses and care workers to be more sensitive to unconscious incidents of neglect or offence that they could have made through ignorance rather than malice. Much of it depends, perhaps, on whether lessons of Mid Staffordshire have been internalised; on carers being trained to care rather than to meet targets.

To demand more training of care workers seems both inadequate and unfair if it is not accompanied by better salaries. In 2009, Andy Burnham, who was enjoying a brief spell as health secretary, admitted that the social care workforce was “in many ways underpaid”, which had led to “pressure” and ensured that “the quality in some parts [wa]sn’t there”. This is not a man to be charged with stridency. In opposition, the ever unhelpful Labour Party has failed to raise even these mildest of observations. Under the Conservatives and Liberal Democrats, meanwhile, amid enthusiastic cost-cutting and privatisation, thing have worsened rather than improved. According to Heather Wakefield of UNISON, more than half of Britain’s care employees have seen their wages decline, despite taking on additional duties.

These miserable rates of pay dissuade good people from applying and attract men and women who are unstable or aggressive enough that they could find nothing else to do. Conscientious employees, meanwhile, have their fine work go unrewarded, and may be so frustrated as to let their standards drop. The worst are enabled while the best are handicapped, and the old and disabled suffer the effects of both.

It is obvious that as millions of men and women shuffle into the social care system its jobs will be too numerous and accessible to be among the most high status of careers. It would enrage us if so little was expected of or given to the people who teach our children or treat our illnesses, though, and I am unsure of the difference here beyond the fact that the victims are too weak to complain about it. Either the money is to be found among our budgets, and the worst profit-seeking habits of private institutions curbed, or we might as well admit to being tolerant of high levels of violence and neglect perpetrated against the weakest among us.

Some of the abusers, though, have been the bosses, not the staff. Their little tyrannies have been preserved by a system that fails to expose abuse or protect whistleblowers who reveal it. Cynthia Bower, the head of the Care Quality Commission, stepped down last year amid justifiable suggestions that the watchdog was a blind old mutt. Citizens who lead the state to crimes, meanwhile, have so little support that many people must have been dissuaded from coming forward. Eileen Chubb, who lost her job after exposing abuse in her workplace, says she was blacklisted by every care home in her area. Now head of the charity Compassion in Care, she argues that legislation “is so badly written that whistleblowers don’t stand a chance”. This must change, or the voiceless will have no one to speak for them.

One might as well end by observing some of the cases that have been exposed or heard in court in the first months of a young 2013. A care worker in Truro seized an autistic man and slammed his head into a door. A nurse in Rosgrove was charged with pushing a woman outside in her nightdress and leaving her to freeze. A nurse in Wales was struck off after spitting, shouting and swearing at residents. Snap inspections have revealed numerous cases of neglect in care homes and hospitals across Britain, including that of an old woman who did not seem to have drunk water in more than half a week.

This is one of those hard problems that defies convenient solutions but that only makes forming a serious response a task of greater urgency. Millions of people, as things stand, will be saved from death to lives in fear and isolation. Such cases as those I have noted, investigators say, probably represent the “tip of the iceberg”.

 

Drugs, Not Working But Worsening…

On Friday I wrote of a study by researchers from Queen’s University Belfast, who have revealed that while 1% of elderly people living alone or with relatives in Northern Ireland are on antipsychotics, 20% of elderly people in its care homes take them. It is predictable that residents of care homes are more likely to endure psychiatric conditions than old people elsewhere but the second figure seems awfully high nonetheless, especially given the concerns that the benefits of the drugs are overstated and their dangers overlooked. Like the idle blogger that I am, I called for more research. This research exists, in fact. What is needed is more action.

The researchers claim that these rate of prescription can be observed across the U.K.. I can find little data to suggest that the difference is as stark as that but this is in large part because more people living alone or with family seem to be on antipsychotics than they suggest. At least until recently, figures in care homes were similar. Last decade studies in Leeds and Bristol reported figures equal to and higher than it. The researchers in Yorkshire observed that few of the elderly people were given the chance to have their condition reviewed while the researchers in the South West bluntly concluded that they had “confirmed suggestions of inappropriate drug use”. These studies prompted the government to commission a report by Professor Sube Banerjee, who concluded that at least 80% of people who were given antipsychotics derived no benefit from them.

That troubled people are drugged into stupors needlessly is a grim enough fact. Yet antipsychotics can also be damaging to one’s health, and have been associated with weight gain, diabetes, hyperlipidemia and cardiac dysfunction, among other unpleasant conditions. Banerjee claimed that for 1% of Britons taking antipsychotics, who number 1,800 people a year, they will cause their deaths. Dr. Tom Smith of St. Mary’s Hospital has described this as a “highly conservative underestimate”.

Measures have been taken to address this phenomenon. Last year the Alzheimer’s Society established a training programme that, acknowledging the ignorance and impatience that can lead carers to medicate rather than engage with patients, aimed to “increase understanding and awareness of dementia and provide tools, ideas and resources to enable staff to provide good quality person-centred care”. Such interventions have been found to lead to dramatic reductions in antipsychotic use. One, by Fossey et al, also observed that there had been no corresponding rise in agitated or disruptive behaviour.

The Department of Health invested £100,000 in the programme. This is good, of course, and there have been signs of improvement, though further studies have suggested that these are exaggerated. I cannot help feeling that the work lacks urgency. The bottom line is that thousands of people are being given drugs that they will not benefit from but that are liable to increase their suffering and, in many cases, kill them, despite a potent alternative being available.

The victims, though, tend to be old people and the sad fact is that once they have disappeared from our society has little interest in them. This is the only explanation for the indifference towards the levels of abuse they face. I have, of course, no wish to demean the carers who do marvellous and regrettably unheralded work across the country but it remains true that tens of thousands of disabled and elderly people are claimed to have endured physical and psychological abuse and neglect. Just last week a home was closed after investigators found that its conditions were so dreadful that one resident had not had her hair washed since September and another had bedsores that were in danger of spreading into life-threatening infections. This, in fact, was one of the less hideous revelations. At least they weren’t beaten up.

Both of these phenomena demand concerted governmental action. The elderly cannot be expected to protect themselves from abuse and nor can they be expected to so much as grasp that they might need protection from drugs. The costs of rising numbers of people in social care, and people suffering from dementia, are extremely serious. There is, though, to draw attention to a neglected interest of mine, far more work that could be done into the science of longevity, which is illuminating means of remaining healthy in old age. One’s diet and lifestyle, for example, affects one’s chances of avoiding cognitive decline. Even if this was untrue, however, it would be grotesque to tolerate the needless suffering of vulnerable people – people, mind you, on whose labours our comfort has been founded – because we think them burdensome. It should make us agitated and disruptive, in a manner than no drugs can fix.

 

A Titanic Moment…

It’s a grim fact of our society that as more and more of us are growing older and older our care for those of us who age or ailments have rendered vulnerable is being exposed as ever more gravely inadequate. An official inquiry into abuse at the Winterbourne View care home, exposed by Panorama last year, has released damning conclusions…

Dr Margaret Flynn, who conducted the Serious Case Review into events at the home, said yesterday that the crimes which came to light are likely to be only the “tip of the iceberg”.

She found that there was “institutional abuse” of patients with restraint used on a daily basis and that vulnerable patients were “chronically under-protected”.

She said that had it not been for the undercover report the abuse would have taken a very long time to come to light, if ever.

Anne Milton, the under-secretary for health, was on the BBC this afternoon assuring us that she’d be striving to ensure that this would not happen again. Again? I’d be surprised if it isn’t happening now. In the midst of cost-cutting, privatisation and institutional upheaval tens of thousands of disabled and elderly people are claimed to have endured physical and psychological abuse and neglect. Many, according to a report by the Equality and Human Rights Commission, have been left depressed, “stripped of self-worth and dignity” and “expressi[ng]…a desire to die”. This is grim enough before one recalls that it was the few incidents of abuse exposed by Panorama in Winterbourne View that provoked the exposure of far more. In care homes where vulnerable adults don’t have the support of the BBC and expert investigators there are surely other frightened, miserable people facing awful treatment.

Drastic changes are needed, to curb the minimisation of services and oversight in the name of profit or “austerity” and to arouse, empower and assure the independence of the regulators that have failed people time and again. But as I have been writing since the documentary was aired it’s not simply a matter of plugging holes within the system but reshaping it. To care for vulnerable people in a considerate manner one has to have great patience and sensitivity. I am sure many underpaid and unqualified employees are smart and decent enough to provide this but the fact is that when expectations and payment are minimal there are bound to be lots of incompetent and dissatisfied people applying. The latter make the abuse inevitable while the former have ensured that thousands of old people aren’t even fed properly.

The extent to which this problem has been ignored is more disturbing evidence that, barring the fortunate souls who have gained attention by virtue of their importance to different ideologies, the extent to which your problems are acknowledged depends on the extent to which you can parade them. Where our governors can’t win attention by opposing grim social phenomena, meanwhile, they’ve shown themselves to be pathetically indolent. No longer. We can face the labour and expense that reform might demand or accept the continuation of this shameful status quo. For compassionate people the answer is surely simple, and the fact that the probable lengthening of our existences has ensured that we’re more liable to end up within the system even the most callous of us might be wise to agree. The problem, of course, is that our governors are privileged enough that they won’t share these worries. Ce’st la bleedin’ vie.

 

Violence And The Voiceless…

Jane Worroll writes, in the Daily Mail…

To all appearances, it was an ordinary digital alarm clock. Except that it wasn’t.

It was a high-resolution, 30-frame remote video surveillance clock purchased for £20 on eBay, and I had bought it for one specific purpose: to record 24 hours in the life of my elderly mother at her North London care home.

My mother had been a resident at Ash Court, a 62-bedroom private care home in Kentish Town, for almost a year.

But I wanted to understand why she wasn’t sleeping, talking or feeding herself any more. She looked so sad, so introverted.

Her grim discoveries will be the feature of a Panorama film tonight. This will hopefully serve to raise public awareness of the abuse of elderly as their exposé of violence in homes for the disabled did last summer. As we know…

Almost 100,000 elderly and disabled people were feared to have suffered abuse at the hands of their carers last year in what ministers described as “an absolute scandal”.

…

More than 34,000 vulnerable adults were alleged to have been hit, slapped, kicked or suffered another type of physical abuse while almost 27,000 allegations of neglect were recorded.

Considering the lengths Ms Worroll had to go to in exposing the abuse of her Mother – the inept watchdog had decreed that her care home was “excellent” – that number could be far higher. What a time, then, to read of a “crisis in care for the elderly”, as town halls are forced to carve up to 10% of funds from their budgets for social care. The government has replaced services with the only resource it’s generous with: airy rhetoric. I think there’s precedent that demonstrates the futility of huffing and puffing at obstacles. With the number of octogenarians and their elders expected to double within years, as well as huge increases among the disabled, this idleness is hugely irresponsible as well as cruel. The least we can do is kick up a stink over it; after all, one of the tragic things  is that the victims can’t.

 

Systematic Failure, Chronic Disregard…

The Equality and Human Rights Commission has found evidence of “systematic failure” in the provision of council-funded home care…

The report which is partly based on the experiences of 1,200 older people, their friends and family, found examples of treatment that including cases of physical and financial abuse. Findings included carers neglecting tasks because councils paid for too little of their time. There was also a chronic disregard for older people’s privacy and a disregard for clients’ dignity when carrying out intimate tasks.

Some instances of care appeared to be less about neglect and more about cruelty. The commission reported some care workers placed food in “front of older deaf/blind people, but did not let them know it was there, or left it in an inaccessible place”.

There was also reporting of sporadic violence against the elderly and the infirm. “The cumulative impact on older people can be profoundly depressing and stressful: tears, frustration, expressions of a desire to die and feelings of being stripped of self-worth and dignity – much of which was avoidable…”

Yes, that’s right: “expressions of a desire to die”.

Liz Kendall, Labour’s shadow minister for care and older people, said: “The government is cutting funding for older people’s social care by £1.3bn in real terms [in] this parliament. These cuts are pushing the system to breaking point. Eight out of 10 councils are now only providing care for those with substantial and critical needs, and 15 minute home visits are all too often becoming the norm.”

This is merely part of the national disgrace that is our provision of care to the aged and disabled. We can hope the spot checks that the Care Quality Commission have announced they’ll undertake will relieve this problem. Still, if incompetence, neglect, and abuse are endemic as they and the EHRC have suggested we’ll need something more dramatic. There aren’t just a few rotten apples to be picked; this tree’s decayed at its roots.

It was Ghandi who said that a nation’s greatness can be measured by how it treats its weakest members. And, if you’re not moved by this, I’d simply remind you that we’re living longer and one day it might be you in need of care.

 

Who Cares?

I’ve written a few times about the grim of levels of abuse in care homes. It’s good to have statistics to back up the anecdotes but it isn’t good to see how grim the statistics are…

Almost 100,000 elderly and disabled people were feared to have suffered abuse at the hands of their carers last year in what ministers described as “an absolute scandal”.

…

A landmark inquiry into the scale of mistreatment disclosed that a quarter of cases involved relatives or carers putting alleged victims under pressure to change their wills, stealing property, or fraud.

…

Social or healthcare workers were the alleged perpetrators in 29% of cases while family members, including the victim’s partner, were suspected of being the abusers in 25% of cases.

I’m no expert on nursing but here’s two points that seem obvious: (a) this is clearly more a case of a rotten orchard rather than bad apples and (b) unlike, say, the army this is not the kind of job that’s liable to produce sociopaths by its very nature. Clearly, then, there’s something wrong with the applicants they’re attracting. I suspect that the position of “carer” needs redefining as more a respectable and, thus, more exclusive position. Harder training wouldn’t just equip people for the role, it’d sort the more determined, conscientious applicants from careless and cynical ones who’ve festered within the system. Better pay would serve to attract this better class of employee, and could ensure that they’re not as frustrated in their work.

In the Question Time after the Panorama exposé of the shocking abuse in the Winterbourne care home a panellist was roundly mocked for implying that there were structural deficiencies that had exacerbated the problem. “Nonsense!” The cry went up. People should be expected not to mistreat the helpless. Well, yes, we should be able to expect that but we can’t. The evidence is in: demanding and confusing jobs, filled by the lowest and most desperate of applicants, are liable to produce employees who lack the receptiveness and sensitivity that’s needed – and, indeed, can be downright sociopathic.

What’s also disturbing is how hard it seems to be to remove such people from their jobs…

The report from the NHS Information Centre shows that only  5 per cent of incidents overall resulted in staff either being sacked or suspended.

And in only 1 per cent of cases were nurses, care workers or other staff referred to watchdogs such as the Nursing and Midwifery Council to investigate whether they should be struck off.

What’s going on here? Abuse of the disabled shouldn’t be a “three strikes and you’re out” sort of thing.

I still think that if this wasn’t care workers but teachers who were being discussed there’d be an outcry so ferocious it would startle the Greeks. And, indeed, this would be right. So, let’s raise our voices here for even more helpless people among us. And, indeed, let’s invest in the elderly for all our sakes. One thing that’s unlikely to recede in future decades is the amount of old people who need looking after.

It’s trivial compared with the significance of these facts but I have one gripe with the Telegraph’s article. They quote someone as saying “urgent attention needs to be paid as to why 96,000 cases of abuse were allowed to happen last year” but they’d already reported that these were alleged abuses and 30% were not “fully or partly substantiated”. That doesn’t mean they were all bogus accusations, no, but some clearly were. This elision of “alleged” and substantiated incidents tarnishes a lot of reportage. People can get confused; people lie. How could they do that? Well, it’s easier to understand than people abusing the disabled.

 

Do We Care?

It’s good to the Care Quality Commission doing its job. On the other hand, it’s sad to see there’s such a need for it…

Care Quality Commission (CQC) inspectors have reported on a series of problems at Ruishton Court Nursing Home in Henlade

…

Poor nutritional leadership had left residents “at risk of malnourishment and dehydration”, and there was “little evidence” to show some residents were given any choice about their care.

This seems revealing…

The CQC said while people who can communicate were treated respectfully, this was less apparent for those who could not communicate as well.

If someone can engage you in a fairly normal manner they’re much easier to deal with than somebody who can’t. You are therefore more inclined to want to engage them. That, at least, is how I’d guess an untrained and perhaps unenthusiastic carer would regard the dwellers of their homes. Why it’s acceptable to employ untrained and unenthusiastic carers is the real question. The consequences should be clear enough. Just today this was disturbingly illustrated…

Twenty-three carers across Lancashire have been dismissed or are under investigation for abusing and mistreating patients…

A Freedom of Information request has revealed eight cases involving physical abuse, four concerning financial and emotional abuse and five cases of verbal abuse across Lancashire County Council’s 17 care homes over the past two years.

The scale of neglect, let alone abuse, is shocking. Last week, admitting to “systemic” failures of care, the CQC apparently reported that thousands of homes…

…were putting elderly people in danger because medicines were not administered safely, while more than 1,600 did not even ensure frail and elderly people got the food and drink they needed.

To be clear – and without the faintest desire to malign the many carers who do proper and valuable work – thousands don’t have the training, patience or compassion to feed, treat and, er, avoid abusing people in their care. I’d humbly suggest that blame lies with the system of employment – and, thus, ownership – not merely employees. That we haven’t realised this could well be due to the sad fact that its victims can’t lobby us.

Update: This blog provides fine and sobering commentary: Care in the UK.

 

Someone Else’s Duty Of Care..

In the week Britain discovered that its care home system is rife with abuse, America discovers that its care home system is rife with abuse…

Jonathan [Carey], a skinny, autistic 13-year-old, was asphyxiated, slowly crushed to death in the back seat of a van by a state employee who had worked nearly 200 hours without a day off over 15 days. The employee, a ninth-grade dropout with a criminal conviction for selling marijuana, had been on duty during at least one previous episode of alleged abuse involving Jonathan.

…

These institutions spend two and a half times as much money, per resident, as the thousands of smaller group homes that care for far more of the 135,000 developmentally disabled New Yorkers receiving services.

But the institutions are hardly a model: Those who run them have tolerated physical and psychological abuse, knowingly hired unqualified workers, ignored complaints by whistle-blowers and failed to credibly investigate cases of abuse and neglect, according to a review by The New York Times of thousands of state records and court documents, along with interviews of current and former employees.

One of the major elements behind the bullying at Winterbourne View, I think, was how devalued the role of care worker seems to have been. They face scant training and, as far as I can tell, there’s next to no discrimination between candidates. Perhaps there aren’t enough of them. The pay is bad enough that this wouldn’t be surprising. Nor is it surprising the role attracts some people who aren’t suitable for the job. Aren’t suitable, in other words, for caring for disabled people. This seems to be dangerously true of the U.S.…

Some workers were hardly fit for duty. One had a history of showing up intoxicated, according to depositions in a civil case brought by the Carey family against the state, but he was kept on the job until he was once so drunk at work that he was sent to a hospital. He was later made a groundskeeper.

Direct-care workers were often high school dropouts, some with criminal convictions. One lower-level supervisor had a petty larceny conviction. Edwin Tirado, the employee eventually convicted of manslaughter in Jonathan’s death, had been convicted of selling marijuana and, as a youthful offender, for firing a shotgun in his attic.

Care workers who deserved the name had nobody to turn to. If you’ve seen my posts on the lackadaisical response to the employee who reported the abuse in Bristol you won’t be surprised to read this tale…

Paul Borer, a dietitian who works for the agency in the Hudson Valley, said he saw another employee punch a resident twice in the face in 2008, but little ever came of the many complaints he made about the episode, to his supervisors, to the commissioner of the agency at the time, Diana Jones Ritter, and to the office of Gov. David A. Paterson.

“You can see a person get hit, then you can go through three years of writing back and forth and nothing happens, so why even report it?” Mr. Borer said.

Another whistleblower filmed two high-ups of the institution shrugging off the charge that an employee had beaten a resident with a stick. We’re told they’ve now been “reassigned”. Reassigned? What would constitute a sackable offence? Hitting someone with a stick? Well, perhaps not…

If the abuse that Panorama and the New York Times reveal had taken place in schools rather than care homes there would be more outrage than a thousand Sachsgates. Rightly. These people are the most vulnerable in our societies and yet many have been tormented while our eyes were fixed elsewhere. If we can’t protect the weakest of us, what can we do?